Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, record review, and facility policy and procedure review, the facility failed to notify
the physician for one (Resident #128) in a total sample of 43 residents, after she choked during the lunch
meal she consumed in her room.
The findings include:
On 04/14/2024 at 12:56 PM, Resident #128 was observed seated in a wheelchair next to the bed of one of
her roommates. She got up from the wheelchair and walked with an unsteady gait and spastic movements
of her hands across the room to her bed. She ran into her tray table and sat down on her bed that was
positioned in the lowest position. The right side of the bed was against the wall and a floor mat was
observed next to the bed. She stood up from her bed and bumped into her tray table again, then dropped
down on her bed. She stood up again and ran into her tray table. She walked in and out of the room with an
unsteady gait and uncoordinated, spastic movements of her limbs. A staff member delivered the resident's
meal tray, set it on her tray table, and told the resident it had been left in her room. Resident #128 came
back into the room, took the meal tray, and placed it on the mattress at the foot of her bed. She then sat
with her legs crossed in front of her and began eating her meal. She took three large bites of the hotdog on
a bun on her plate. She then got up off the bed, holding the hotdog, and started walking around her room
bumping into things. She appeared to be choking. Her roommate engaged the call light, the assigned
nurse, Licensed Practical Nurse (LPN) F, entered the room a few seconds later and performed the Heimlich
maneuver on Resident #128. The resident coughed up three large bites of hotdog and bun. The nurse
asked the resident if she could speak to ensure she had cleared her airway. The resident stated she was
okay. Resident #128 then went over and sat on her bed. She did not continue to eat right away but did not
appear to be in further distress. After a few minutes, she got up and walked out of the room.
On 04/15/2024 at 10:20 AM, Resident #128 was observed lying on her bed, face down, with her face
turned toward the wall. Her eyes were closed and she did not appear to be in any distress.
On 04/15/2024 at 3:05 PM, a review of the resident's progress notes, revealed a note dated 04/14/2024 at
3:03 PM, which read: Resident experienced difficulty swallowing today at noontime. She was eating a
hotdog and was unable to swallow it properly. (Photographic evidence obtained) There was no indication in
the medical record that the physician or the resident's family/representative were notified of the incident.
On 04/15/2024 at 3:07 PM, a review of the active physician's orders revealed no order for a Speech
Therapy (ST) screening or evaluation. (Copy obtained)
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
105287
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105287
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westside Oaks Rehabilitation & Nursing Center
2061 Hyde Park Rd
Jacksonville, FL 32210
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 04/15/2024 at 3:10 PM, a review of the resident's active care plan, dated 03/14/2024, revealed no care
plan was in place related to swallowing difficulties. (Copy obtained)
On 04/16/2024 at 4:26 PM during an interview with Speech Therapist (ST) E, he stated he had never
screened or evaluated Resident #128. He had not been asked to evaluate her. He was not aware of an
incident involving her choking.
A review of the medical record revealed that Resident #128 was admitted on [DATE]. Her diagnoses
included Huntington's disease, unspecified dementia - severe with psychotic disturbance, major
depression, and dementia in other diseases classified elsewhere - mild with agitation.
On 04/17/2024 at 10:18 AM, an interview was conducted with Resident #128 in her room. She stated she
remembered choking on 04/14/2024. She stated, I put too much food in my mouth.
On 04/17/2024 at 11:01 AM during an interview with LPN F, she stated she had been through the facility's
orientation process but she did not know all of the facility's policies. She stated the protocol for notifying the
physician was to contact the physician when there was something major happening with a resident. When
Resident #128 choked on 04/14/2024, she stated she asked other nurses if she should contact the
physician. She spoke with the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and the
Unit Manager (UM). She was told by the ADON that she (ADON) would contact the physician and the
therapy department in order to have the resident evaluated. She stated, I think she (Resident #128) needs
to be evaluated for a swallowing disorder. She confirmed that the physician should be notified but that she
had not done it.
On 04/17/2024 at 4:29 PM, a review of the active physician's orders revealed no new order for a Speech
Therapy evaluation or screening since the date of the choking episode on 04/14/2024.
A review of the Annual Minimum Data Set (MDS) assessment, dated 03/15/2024, revealed that Resident
#128 had a Brief Interview for Mental Status (BIMS) score score of 00 out of 15 possible points, indicating
severe cognitive impairment. She had no signs or symptoms of a swallowing disorder. She ate by mouth
only. She had no dental problems. She did not receive any special treatments or skilled therapy.
On 04/18/2024 at 10:20 AM, the resident's primary care physician was contacted via telephone. The
physician stated she had not been contacted regarding Resident #128's choking incident on 04/14/2024.
She stated her Advance Practice Nurse Practioner (APRN) may have been notified.
On 04/18/2024 at 10:25 AM during an interview with the DON, he stated he was not aware of Resident
#128's choking incident on Sunday, 04/14/2024.
On 04/18/2024 at 11:07 AM during an interview with the ADON she shook her head and stated, I have not
heard of any incident with [Resident #128]. She was asked to confirm with APRN G whether he was
contacted regarding the choking incident on 04/14/2024. The ADON called APRN G and when he
answered the telephone, the ADON put him on speaker. He confirmed that he was following Resident #128.
Without being asked, he stated he had not been contacted by the facility regarding a choking incident for
Resident #128. He confirmed that the primary care physician had spoken with him this morning to
determine whether he had been contacted regarding the choking incident. He stated, If the nurse had to
use the Heimlich maneuver to clear the airway for the resident, it was a pretty intensive intervention. I would
expect the staff to contact me immediately after that happened. He confirmed that it was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105287
If continuation sheet
Page 2 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105287
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westside Oaks Rehabilitation & Nursing Center
2061 Hyde Park Rd
Jacksonville, FL 32210
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
not uncommon for residents who had a diagnosis of Huntington's disease to develop swallowing difficulty
as part of the progression of the disease, and he would have ordered a Speech Therapy evaluation for the
resident had he been informed.
A review of the resident's progress notes revealed a note dated 04/18/2024 at 11:57 AM, which read:
Resident was observed choking on her lunch. Heimlich maneuver was performed on the resident to clear
what was blocking resident's airway. Airway was cleared. NP (Nurse Practitioner) notified and [resident's
spouse] was notified. No new orders. (Copy obtained)
A review of the facility's policy and procedure titled Change in a Resident's Condition or Status (Notification
of Change), revealed:
The Center shall promptly notify the resident, his or her attending physician, and representative of change
in the resident's condition/status. 1. The Center designee will notify the resident's attending physician when:
f. Deemed necessary or appropriate in the best interest of the resident. (Copy obtained)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105287
If continuation sheet
Page 3 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105287
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westside Oaks Rehabilitation & Nursing Center
2061 Hyde Park Rd
Jacksonville, FL 32210
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, record review, and facility policy review, the facility failed to ensure that one
(Resident #116) of 43 sampled residents received necessary services to maintain good grooming, by failing
to ensure his fingernails were trimmed/clipped.
Residents Affected - Few
The findings include:
On 04/17/24 at 10:51 AM, an observation of Resident #116 revealed that all of his fingernails on both
hands were dark yellow and elongated. They extended approximately 1/4 inch beyond the tip of each finger.
The resident reported that he did not like his fingernails so long.
On 04/17/24 at 11:43 AM, another visit was made to Resident #116's room and photographs were taken,
with his permission, of both hands, which remained in the same condition as they were on 04/17/24 at
10:51 AM.
A review of the medical record revealed that he was admitted to the facility on [DATE] with diagnoses
including monoplegia of upper limb following unspecified cerebrovascular disease affecting left dominant
side, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, hyperlipemia,
pain, and hypertension.
A review of the Minimum Data Set (MDS) assessment, dated 02/29/24, revealed a Brief Interview for
Mental Status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. He was documented
with a range of motion (ROM) impairment on one side and required assistance with personal hygiene.
A review of the care plan, initiated on 02/19/24, revealed a focus area noting the resident had an Activities
of Daily Living (ADL) Deficit in self-care performance due to fatigue and impaired balance. The care plan
goal included that the resident's needs would be met. Interventions included the provision of personal
hygiene with partial to moderate assistance.
On 04/18/24 at 11:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) C, who
reported that he had been employed with the facility part-time for three weeks. He explained that either he,
or the Activities Director, whoever noticed excessive long fingernails first, would either clip or file a
resident's fingernails. He explained that he was not certain where he would document the assistance of
clipping or filing a resident's fingernails. He further explained that whenever providing ADL care, he
completed a body visual check for cleanliness and fingernail length. When he was asked whether he
noticed Resident #116's fingernails, he stated, Today I noticed his fingernails were long, and I was planning
to file or clip them after I finished my charting. CNA C further explained that yesterday was his first day
assigned to provide services for this resident. He expressed that he received ADL care training during his
orientation three weeks ago. The employee verified that CNAs should be looking at the condition of the
resident, including length of nails while providing care to residents.
On 04/18/24 at 11:24 AM, an interview was conducted with Registered Nurse (RN) D, who reported that
she had been employed with the facility for one and a half years. She explained that CNAs and nurses
clipped and filed residents' fingernails. She further explained that while providing medication administration
services, nurses should be taking notice if a resident's fingernails are excessively
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105287
If continuation sheet
Page 4 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105287
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westside Oaks Rehabilitation & Nursing Center
2061 Hyde Park Rd
Jacksonville, FL 32210
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
long. If she were to observe a resident with long fingernails, she would ask permission from the resident to
trim the fingernails and obtain fingernail clippers from central supply. She would then glove up and trim the
resident's fingernails. After trimming a resident's fingernails, she would document it in a progress note in
the facility's electronic medical record. When she was asked about the condition of Resident #116's
fingernails, she stated, [Resident's name] requires care in ADLs. I noticed the resident's nails were long this
morning while administering medications. She explained that she had been working in the C hall (where
Resident #116 resides) for a while, and that today was the first time she noticed the resident's fingernails
were excessively long. She reported that she received ADL training during orientation.
A review of the facility's policy and procedure titled Activities of Daily Living (ADLs) Maintain Abilities
(Undated0, revealed that the intent of the policy was to create and sustain an environment that humanizes
and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments,
understand the principles of quality of life, and honor and support these principles for each resident; and
that the care and services provided are person-centered, and honor and support each resident's
preferences, choices, values and beliefs in order to achieve and or assist the resident in attaining the
highest physical abilities. 3. The facility will provide care and services for the following activities of daily
living a) Hygiene-bathing, dressing, grooming, and oral care. 4. A resident who is unable to carry out
activities of daily living will receive the necessary services to maintain good nutrition, grooming .
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105287
If continuation sheet
Page 5 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105287
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westside Oaks Rehabilitation & Nursing Center
2061 Hyde Park Rd
Jacksonville, FL 32210
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interviews and document review, the facility failed to store and prepare food in
accordance with professional standards for food service safety, by failing to ensure kitchen equipment was
clean and opened food was labeled, dated and sealed for 162 residents who received food from the
facility's kitchen.
The findings include:
On 04/14/24 between 11:28 AM and 11:39 AM, the following items were observed in the kitchen's dry
storage area: An open, undated and unsealed bag of potato chips, opened, undated penne pasta noodles,
and opened, undated, unsealed Classic [NAME] Quick Grits mix. (Photographic evidence obtained)
On 04/14/24 at 11:15 AM, two bags of opened, undated wheat bread were observed in the kitchen prep
area. (Photographic evidence obtained)
On 04/14/24 at 11:42 AM, the cook top and three sides of the kitchen's stove were observed covered with
food debris, grease and grime. The interior of two ovens under the stove were also covered with food
debris, grease and grime. (Photographic evidence obtained)
On 04/14/24 at 11:46 AM, a cleaning schedule dated 04/12/24, was observed taped to a wall in the kitchen
and noted an employee was assigned to deep clean the oven and stoves in the cook area that day.
(Photographic evidence obtained)
On 04/14/24 between 11:49 AM and 11:54 AM, the following items were observed in the kitchen's walk-in
refrigerator: An unsealed, dated (4/12/24 prep date) canister of battered fish; a canister of opened, canned
pineapple without a label or date; an open and undated bag of shredded lettuce; an unsealed, undated
opened bag of iceberg lettuce heads; an undated, opened bag of chopped green peppers, and an opened
and unsealed bag of chicken thighs. (Photographic evidence obtained)
On 04/14/24 at 12:08 PM, an opened, unsealed bag of frozen biscuits was observed in a reach-in freezer in
the kitchen. (Photographic evidence obtained)
On 04/15/24 at 9:06 AM, a second observation was made of the kitchen's cooktop and three sides of the
stove, which were covered with food debris, grease and grime, as well as the interior of two ovens under
the stove that were covered with food debris, grease and grime. (Photographic evidence obtained)
On 04/15/24 at 9:53 AM, a second observation was made in the kitchen of an unsealed bag of chicken
thighs and an unsealed, undated opened bag of iceberg lettuce heads in the walk- in refrigerator. A second
observation was made of an open, undated bag of penne pasta in the dry storage area. (Photographic
evidence obtained)
On 04/15/24 at 9:59 AM, a second observation was made of an open, unsealed bag of frozen biscuits in
the kitchen's reach-in freezer. (Photographic evidence obtained)
On 04/15/24 at 10:02 AM, an open, unsealed bag of tortillas was observed in the kitchen's walk-in
refrigerator. (Photographic evidence obtained)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105287
If continuation sheet
Page 6 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105287
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westside Oaks Rehabilitation & Nursing Center
2061 Hyde Park Rd
Jacksonville, FL 32210
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
On 04/18/24 at 10:40 AM, an interview was conducted with the Certified Dietary Manager (CDM). She
stated she had been employed with the facility for eleven months. She explained the process to ensure that
kitchen area cleanliness was maintained included both she and the kitchen supervisor checking the daily
cleaning schedule. The CDM created a bi-weekly cleaning schedule, and the supervisor created a daily
cleaning schedule. The CDM and kitchen supervisor made daily sweeps of the kitchen to determine what
needed to be cleaned. A cleaning schedule was created and hung on the window in the main area of the
kitchen. Staff were trained to check the cleaning schedule at the beginning of each shift. The CDM and
supervisor checked daily to ensure kitchen staff had completed and signed off on their assigned cleaning
tasks. She further explained that the dietician made a thorough assessment of the kitchen area and created
a monthly sanitization report for items needing cleaning. The CDM reported that opened, perishable food
was only good for three days in the walk in refrigerator. Employees should place opened food in a closed
container or wrapped in plastic, labeled and dated. The same process should be used for opened,
non-perishable food stored in the dry storage area.
On 04/18/24 at 10:52 AM, the CDM verified the condition of the stove and ovens layered with food, grease
and grime. She explained they had a floor technician who pressure washed once a month, which included
cleaning the inside and outside of the stove and ovens. She further explained that the stove and ovens
should be cleaned on a regular basis outside of the monthly pressure washing.
A review of the facility's protocol (Undated) related to opened food, revealed the requirement to label food
not stored in original containers, mark dates after opening or preparation.
The facility's policy titled Leftovers (Dated April 2022), revealed: It is the dietary department's goal to
maximize food usage in order to avoid waste. To this end, certain leftover foods are reused with restrictions.
5. Cover, label and date all containers with the date that the food was first prepared or thawed.
A review of the facility's policy titled Cleaning and Sanitation of Food Service Area (Undated), revealed: The
food service staff will maintain the sanitation of the dining and food service areas through compliance with
a written, comprehensive cleaning schedule. 5. Staff will be held accountable for cleaning assignments.
A review of the facility's cleaning protocol (Undated), documented how to clean the inside of an oven.
.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105287
If continuation sheet
Page 7 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105287
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westside Oaks Rehabilitation & Nursing Center
2061 Hyde Park Rd
Jacksonville, FL 32210
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and a review of the policy and procedure for Maintenance Services, the facility
failed to ensure the floors on hallways A, B and C as well as one (room [ROOM NUMBER]) of 53 rooms
were safe and without accident hazards. Staff, residents, and visitors were at risk for falls due to the raised
floor boards and a missing area of floor board in the aforementioned areas of the facility.
The findings include:
On 4/14/24 at 11:45 a.m., hallway A, Unit 1 was observed with raised floor boards in multiple areas which
presented a tripping hazard. There is also a hole in one of the floor boards entering the hallway. room
[ROOM NUMBER] had multiple floor boards which had separated from other boards leaving spaces open
which were a tripping hazard. (Photographic evidence obtained)
On 4/14/24 at 1:33 p.m., a family member reported that the floors in the hallways and the floor in room
[ROOM NUMBER] were tripping hazards; she had tripped twice. She reported the flooring was raised in the
room and hallways, and it had been reported to management but nothing had been done about it.
An interview was conducted with the Director of Plant Operations on 4/18/24 at 10:15 a.m. He was
accompanied on a tour of the hallways on Units 1 and 2. He confirmed the hole in the flooring at the
beginning of the Unit 1 hallway. He toured the unit and confirmed the concerns in the A, B, and C hallways
with A being the worst. Multiple floor boards were raised on that hallway. He reported the old glue was
loosening up and raising the boards causing bubbles. In room [ROOM NUMBER], he confirmed the floor
boards were separating, and there were spaces between the floor boards. He confirmed that the raised
floor boards were a tripping hazard.
The Environmental Performance Improvement Plan was reviewed which started on 3/21/24. The EPIP
focused on the age of the building, housekeeping, and work orders being completed timely. Housekeeping
was retrained and staff were retrained on placing work orders. A review of the Angel rounds for the past
week noted no acknowledgment of the floors being a trip hazard or any concerns about the flooring. Most
comments concerned the floors being soiled. Nothing reviewed addressed holes in the flooring or raised
flooring causing a tripping hazard.
The Maintenance Service Policy and Procedure (Dated April 2022) was reviewed. Under Section 2,
following functions performed by maintenance: Maintaining the building in good repair and free from
hazards.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105287
If continuation sheet
Page 8 of 8
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the April 18, 2024 survey of WESTSIDE OAKS REHABILITATION & NURSING CENTER?
This was a inspection survey of WESTSIDE OAKS REHABILITATION & NURSING CENTER on April 18, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESTSIDE OAKS REHABILITATION & NURSING CENTER on April 18, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.